East Gippsland Primary Care Partnership. Assessment of Chronic Illness Care (ACIC) Resource Kit 2014

Transcription

1 East Gippsland Primary Care Partnership Assessment of Chronic Illness Care (ACIC) Resource Kit

2 Contents. 1. Introduction 2. The Assessment of Chronic Illness Care 2.1 What is the ACIC? 2.2 What's involved in completing the ACIC? 2.3 The ACIC in East Gippsland 2.4 Plan Do Study Act (PDSA) cycles 2.5 Agency Checklist for the Successful Coordination of the ACIC 3. The Chronic Care Model 3.1 Organisation of the Healthcare Delivery System 3.2 Community Linkages 3.3 Self-Management Support 3.4 Decision Support 3.5 Delivery System Design 3.6 Clinical Information Systems 4. Next Steps 5. References and Resources 6. Appendix 2

3 1. Introduction The Department of Health stipulate annual reporting requirements for the Primary Care Partnerships (PCPs). One area which is reported against is the Integrated Chronic Disease Management priority area, which is a component of the Primary Care Partnership Program Logic Domain 1: Early Intervention and Integrated Care. The objective of this domain is to strengthen the primary health system to deliver person centred and accessible early intervention and integrated care that aims to keep people as well as possible for as long as possible, particularly people with complex needs. In 2014, PCPs are required to submit an Assessment of Chronic Illness Care (ACIC) and catchment based improvement plan. The ACIC is strongly aligned with the Wagner Improving Chronic Care Model (CCM) and can be implemented broadly within a catchment to assess organisation-wide systems for chronic illness care. 2. The Assessment of Chronic Illness Care 2.1 What is the ACIC? The ACIC is a practical tool which assesses an organisation s current performance with regards to chronic disease management against the elements of the CCM, helps those involved to identify areas for improvement, and allows for repeat assessment to determine the effectiveness of the implemented improvement strategies. 3

4 The ACIC consists of seven elements. These are listed in the diagram below. 4

5 The ACIC is designed to assess each of the six elements of the CCM, with the seventh element included to assess the integration of these six elements. Each element is assessed through questions related to specific components within it. The break down of each element can be seen in the images that follow. Overall organisational leadership in chronic illness care Organisational goals for chronic care Improvement strategy for chronic illness care Incentives and regulations for chronic illness care Senior leaders support for chronic illness care Benefits Linking clients to outside resources Partnerships with community organisations Regional health plans 5

6 Assessment and documentation of selfmanagement needs and activities Self-management support Addressing concerns of clients and families Effective behaviour change interventions and peer support Evidence-based guidelines Involvement of specialists in improving primary care Provider education for chronic illness care Informing clients about guidelines 6

7 Practice team functioning Practice team leadership Appointment system Follow-up Planned visits for chronic illness care Continuity of care Registry (list of clients with specific conditions) Reminders to service providers Feedback Information about relevant subgroups of clients needing services Client treatment plans 7

8 Informing clients about guidelines Information systems/registries Community programs Organisational planning for chronic illness care Routine follow-up for appointments, client assessments and goal planning Guidelines for chronic illness care 2.2 What's involved in completing the ACIC? In East Gippsland, the ACIC will be implemented in each agency that has a Community Health service. It can be completed by department managers to provide answers which can be averaged out to obtain a total score for each community health agency or it can be completed in small working groups, consisting of a mix of people who work in chronic illness care, whereby members come to a consensus on the score for each question. This can occur in a single session or over a series of meetings. On average the ACIC can be completed in 90 minutes. 8

9 The ACIC involves answering 34 questions which require a rating of the degree to which each component is being implemented, using a scale ranging from 0 (not at all) to 11 (fully). To help in choosing a score, the ACIC provides general descriptions for limited, basic, good and excellent support of chronic illness care for each component. Scoring interpretation guidelines are as follows: Between "0" and "2" = limited support for chronic illness care Between "3" and "5" = basic support for chronic illness care Between "6" and "8" = reasonably good support for chronic illness care Between "9" and "11" = fully developed chronic illness care It is very common for agencies to begin by obtaining average scores below "5" on many (or all) areas of the ACIC. Over time, as agencies make changes to improve chronic illness care, they should see overall improvements in their ACIC scores. To best see this change in scoring, the ACIC should be completed every two years. The same participant mix, methodology and process should be followed each time the tool is applied to ensure consistency and validity of results. 2.3 The ACIC in East Gippsland Once each agency has completed the ACIC, the East Gippsland Primary Care Partnership (EGPCP) will analyse the results and prepare an improvement plan which will show areas for improvement across each of the components for each 9

10 agency. Each improvement area identified can then be focused on and Plan Do Study Act cycles can be completed to make improvements. All agency scores are confidential and will only be used to highlight areas for chronic disease management improvement. The EGPCP will also develop a catchment based improvement plan to identify the improvements required for optimal chronic illness care across East Gippsland. The identified improvement areas will be incorporated into the operational plan for the next planning cycle. This will allow for the linking of agencies to enable the sharing of knowledge and resources to build capacity and achieve better chronic disease care across the catchment. The confidentiality of agency scores will also be maintained throughout the development of this catchment wide improvement plan. 2.4 Plan Do Study Act (PDSA) cycles Following the completion of the ACIC and identification of areas for improvement Plan-Do-Study-Act (PDSA) cycles can be conducted. PDSA is a problem-solving model used for improving a process or creating a change. It forms part of a framework for developing, testing and implementing changes leading to improvement. This framework includes three questions which should be answered prior to beginning a PDSA cycle: 1. What are we trying to accomplish? 2. How will we know if a change is an improvement? 3. What changes can we make that will result in improvement? 10

11 Following this the process of working through the cycle can begin. A template is included at the end of this resource. Act Plan the next cycle Decide whether the change can be implemented Study Complete the analysis of the data Compare data to predictions Summarise what was learned Plan Define the objective questions and predictions Plan to answer the questions Who? What? Where? When? Plan data collection to answer the questions Do Carry out the plan Collect the data Begin analysis of the data The first stage of the cycle is Plan. This involves developing a plan in regards to what will be done, who will be involved, when it will happen, where it will happen, what you think the result will be, and what data will need to be collected to determine if the improvement has occurred. The second step is Do. This involves doing what you described in the planning stage and gathering data throughout this process to determine the effectiveness of your actions. 11

12 The third step is the Study stage and this involves reviewing what was done to see if the desired improvement was reached and what could be done differently. The final step is the Act stage. This involves deciding if another PDSA cycle is required based on the learnings of this cycle or deciding to adopt the new changes and move forward. PDSA cycles allow for the testing of improvements on a small scale before implementing them across an organisation. By building on what has been learned from these cycles in a structured way, new ideas can be put in place with greater chances of success. 2.5 Agency Checklist for the Successful Coordination of the ACIC The following page contains a checklist that can be used by your agency to support the successful coordination of the ACIC. 12

13 Steps Activity Details Date by Review the ACIC Resource Kit provided to you by the EGPCP Completed (tick) Comments Decide how the ACIC should be coordinated: Who should coordinate the ACIC? Which programs and staff in your agency should participate in the ACIC? What methods will you use for data collection? - small working group - complete the ACIC individually then average the results Are meetings or presentations necessary to educate staff about the ACIC (possible dates and venue for these)? Decide the date that you will complete the ACIC (must be completed by the 9 th December 2014) Plan how you will link the ACIC findings to quality improvement within your programs and in your organisation 13

14 3. The Chronic Care Model (CCM) The CCM identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements should all be implemented simultaneously to create the most positive outcomes. Community Resources and policies Health Systems Organisation of health care Selfmanagement support Delivery system design Decision support Clinical information systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes A detailed description and the aims of each element of the CCM is provided on the pages that follow. Information on ways that agencies can integrate each element into chronic care practice is also included. 14

15 3.1 Organisation of the Healthcare Delivery System Create a culture and mechanisms that promote safe, high quality care in the organisation. Effective organisations try to prevent errors and care problems by reporting and studying adverse events and making appropriate changes to the system. Breakdowns in communication and care coordination can be prevented through agreements that facilitate communication and data sharing as clients navigate across settings and providers. Aims To visibly support quality improvement at all levels of the organisation, beginning with senior practitioners. To promote effective improvement strategies aimed at comprehensive system improvement. To encourage open and systematic handling of errors and quality problems to improve care. To develop agreements that facilitate care coordination within and across organisations. To ensure that high quality service is provided to achieve accreditation. To utilise the Plan, Do, Study, Act (PDSA) cycle to ensure a common and comprehensive approach to quality improvement. Agency responsibilities Train staff in the Plan, Do, Study, Act model. Provide resources to undertake quality improvement projects. Ensure staff have access to computers. Ensure that senior leaders support and are involved in the program. Recognise and promote the achievements of the team. Be available to attend local events and promotional campaigns. 15

16 Essential Process Steps: Step 1: Make improving chronic care a part of the planning processes within the organisation Step 2: Make sure senior staff openly support and promote the efforts to improve chronic care Step 4: Integrate quality improvement into all organisational processes Step 3: Assign day-today leadership for continuing clinical improvement 16

17 3.2 Community Linkages Mobilise community resources to meet needs of clients. The chronic care model relies on the community playing a pivotal role in supporting chronically ill clients. This element is focussed on considering how the community can support and/or enhance the care support systems. Aims Encourage clients to participate in effective community programs by providing them with information on the support services available. Form partnerships with community organisations to support and develop interventions that fill gaps in needed services. Advocate for policies to improve client care. Involve external agencies, for example local universities, to provide clinical and demographic data to help inform quality improvement. Keep the general community aware of the management of chronic disease by attending community events. Agency responsibilities Be supportive and proactive in securing support from community organisations. Seek opportunities for support from other organisations. Develop collaborative relationships with community representatives. Provide support for interpreter services. Provide information on grants that are available. 17

18 Essential Process Steps: Step 1: Establish linkages with organisations to develop support programs and policies Step 2: Link to community to assist with costs of medication, education resources and materials 2 Self-management Step support 4: Step 3: Raise community awareness through networking, outreach and education Encourage participation in community education classes and support groups Step 5: Provide a list of community resources to clients, families and staff 18

19 3.3 Self-Management Support Empower and prepare clients to manage their health and healthcare. Self-management is the element that focuses on ensuring patients have the opportunity to participate in the management of their condition and empowering them to do so. Aims Facilitate clients central role in managing their own health by using an individualised self-management care plan. Provide basic information on the client s disease. To use effective self-management support strategies that include assessment, goal setting, action planning, problem solving and follow up. To organise internal and community resources to provide ongoing selfmanagement support to clients. Agency responsibilities Acknowledge clients central role in their care. Recognise that the role of healthcare providers is to foster a sense of responsibility for the client s own health and provide support to enable them to make decisions. Encourage clients to engage in behaviours that affect their own health. Implement evidence based programs that provide basic information, emotional support, and strategies for living with a chronic illness. Work collaboratively with clients to help them define problems, set goals and priorities and to learn together how to problem-solve. Each agency has the responsibility to ensure that their staff will: Have access to training on how to support the principles of self-management. Develop and introduce evidence based self-management programs. Ensure that the team is empowered to make the necessary changes required to facilitate self-management. 19

20 Essential Process Steps: Step 1: Identify selfmanagement tools that are evidence based Step 2: Establish and document selfmanagement goals collaboratively with clients Step 4: Follow up and monitor selfmanagement goals and action plans Step 3: Train providers and other key staff on how to help clients with selfmanagement goals Step 5: Use group visits to support selfmanagement Step 6: Build community resources to support selfmanagement goals 20

21 3.4 Decision Support Promote clinical care that is consistent with scientific evidence and client preferences. In order to successfully manage chronic disease, clinical decisions need to be based on sound evidence that is supported by research. This information can then be passed on to clients so that they can understand the principles behind their own care and make the appropriate decisions. Aims Embed evidence based guidelines into the care delivery system. Include the use of a structured assessment to diagnose and determine severity of illness for all clients. Establish linkages with key specialists to ensure that primary care providers have access to expert support. Ensure that care is provided by the multidisciplinary team, particularly for more complex patients. Provide skill-focused training programs for all staff in support of chronic illness improvement. Educate clients about guidelines and best practice as part of their own decision support. Agency responsibilities Ensure that all staff members are well trained in the current approaches to evidence based care. Ensure that there are computers with internet access available. Educate staff on how to undertake a literature search and write a guideline. Provide financial support for staff to attend conferences and training programs. Implement guidelines through timely reminders, feedback, standing orders and other methods that increase their impact on clinical decision making. 21

22 Essential Process Steps: Step 1: Embed evidence based guidelines into daily practice Step 2: Establish linkages with key specialists to ensure that primary care givers have access to expert support Step 4: Educate clients about guidelines Step 3: Provide skill orientated interactive training programs for all staff 22

23 3.5 Delivery System Design Assure the delivery of effective, efficient clinical care and selfmanagement support. Improving the healthcare of people with chronic disease requires transforming a system that is often rigid and not designed to support the chronically ill person. It is normally a system that responds well to an acute illness but is generally less capable of providing support for chronic disease. Delivery system design occurs primarily through clarifying roles and responsibilities of healthcare team members. In addition, service providers have a clear understanding of each other s role and a thorough knowledge of what services are available and how to access them. Aims Develop or strengthen the multidisciplinary and/or multi-agency approach for the management of clients with a chronic disease. Define the roles, tasks and responsibilities of each team member involved in the care of a client with a chronic disease. Work collaboratively to provide a streamlined approach to client care in the most effective and efficient manner. Develop standardised care plans and assessment tools. Ensure timely, planned follow up to review care plans and for check ups, e.g. foot clinic. Ensure planned visits in the group and individual settings. Agency responsibilities Understand the roles and responsibilities of each team member. Use planned interactions to support evidence based care. Ensure that all staff are fully familiar with and utilise the Interagency Referral Protocol and are committed to collaborative, cooperative and coordinated working arrangements between service providers. Maintain comprehensive knowledge of the service system within the relevant parts of the region. Be fully familiar with the relevant guidelines for completing the Service Coordination Tools and understand the importance of accuracy, detail and legibility when completing referral documentation. 23

24 Essential Process Steps: Step 1: Use the Patient Registry to proactively review care and plan follow up Step 2: Assign roles, duties and tasks for planned visits for the multidisciplinary team 2 Self- Step 4: Make designated staff responsible for follow up by various methods, including outreach, telephone calls and home visits Step 3: Use planned visits in individual and group settings Step 5: Ensure that appointment systems support the needs of clients for urgent visits Step 6: Ensure that service providers can efficiently and effectively make and receive referrals to reduce inappropriate referrals 24

25 3.6 Clinical Information Systems Organise client and population data to facilitate and monitor efficient and effective care. The clinical information system is an integral part of ensuring all the other elements are linked and coordinated. Practitioners need timely and relevant access to clinical data and population health data. This may include key outcome measures, client history, reminders, how often they have been seen, and attendance at self-management groups. Aims Develop a registry that will capture data that can be used for planning for population health and for individual care plans. Identify relevant sub populations for proactive care. Monitor performance of practice teams and the care system. Gather data collection tools to ensure standardisation of data. Agency responsibilities Service providers have access to relevant data collection software (eg. Medical Director). Ensure staff have access to computers. Staff are trained in the use of data collection software. Population data that is to be included in data collection is communicated to the clinic. Data definitions are established to ensure standardisation across the region. 25

26 Essential Process Steps: Step 1: Establish a client registry Step 2: Develop processes for use of the registry, including designating personnel to enter and maintain data 2 Self- `1 Step 4: Use the registry to provide feedback to healthcare providers and clinic team Step 3: Use the registry to generate reminders and care planning tools for individual clients 26

27 4. Next Steps Once you have reviewed this resource kit you can complete the survey. As previously stated, those involved in completing the ACIC can do so on an individual basis and the results averaged to achieve an overall score for each agency, or the ACIC can be completed in a small working group where consensus can be reached on each rating. The completed survey should then be provided to the EGPCP who will collate the results. The EGPCP will then arrange meetings with each agency to provide the results of the ACIC and discuss the development of an improvement plan. PDSA cycles can then be commenced within each agency. 27

28 5. References and Resources Better Health in Gippsland (2007). Chronic Disease Management: Resource Kit, Victoria. Department of Health (n.d) Chronic Disease Management Audit tools: A fact sheet for Primary Care Partnerships. Available from Improving Chronic Illness Care (2014). The Chronic Care Model. Available from del&s=2 Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P. (2009). The Improvement Guide: A Practical Approach to Enhancing Organization Performance (2nd Ed.). Jossey Bass, San Fransico. NHS Institute for Innovation and Improvement (2013). Quality and Service Improvement Tools: Plan, Do, Study, Act (PDSA). Available from _and_service_improvement_tools/plan_do_study_act.html 28

29 6. Appendix Primary Care Partnerships Annual reporting requirement Assessment of Chronic Illness Care (ACIC) June 2014 In 2014, Primary Care Partnerships are required to submit an Assessment of Chronic Illness Care (ACIC) and catchment based improvement plan to their Regional Director, Health & Aged Care by 31 October Those PCPs that undertook the ACIC in 2013 can submit a new ACIC demonstrating broader agency engagement in 2014 or a progress report based on progress against their 2013 improvement plan. This guide sets out requirements regarding the ACIC process, ACIC methodology and Action Plan. Background This document describes the reporting requirements for Integrated Chronic Disease Management (ICDM) as a component of the Primary Care Partnership Program Logic Domain 1: Early Intervention and Integrated Care. The objective of this domain is to strengthen the primary health system to deliver person centred and accessible early intervention and integrated care that aims to keep people as well as possible for as long as possible, particularly people with complex care needs. PCPs will demonstrate improvement against the key domains of the Assessment of Chronic Illness Care (ACIC) Survey- Integration of Chronic Care Model components scale- Organisational planning for chronic illness care. The Wagner Chronic Care Model 29

30 The Chronic Care Model (CCM) identifies the six essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidencebased change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The Model can be applied to a variety of chronic illnesses, health care settings and target populations. The ACIC Survey The content of the ACIC was derived from specific evidence-based interventions for the six components of the Wagner Chronic Care Model. Like the Chronic Care Model, the ACIC addresses the basic elements for improving chronic illness care at the community, organization, practice and patient level. The ACIC is strongly aligned with the Wagner improving chronic care model and can be implemented broadly within a catchment to assess organisation-wide systems for chronic illness care. General guidelines for the ACIC Assessment of Chronic Illness Care The ACIC is used as a continuous improvement approach to broadly assess organisation-wide systems for chronic illness care. The ACIC survey is undertaken within the context of an ongoing quality improvement process and presents an opportunity to explore the integration of chronic disease components as outlined in the Chronic Care Model and facilitates discussions to further improve ICDM practice. The ACIC Survey also provides evidence of quality approaches to ICDM. The ACIC (version 3.5) has 34 questions divided into seven sections. There is one section for each of the six elements of the Wagner model and a seventh section to assess the integration of these elements, which recognises their interdependence. 1. Organisational Support refers to creating a culture, organisation and mechanisms that promotes safe, high quality care. 30

31 Agencies should consider practice capacity and resources to provide chronic disease care in accordance with best practice recommendations. 2. Community Linkages refers to mobilising community resources to meet the needs of consumers and encourages consumer participation. Agencies should consider practice capacity to link effectively with other providers to provide comprehensive and integrated care. 3. Self-Management Support - refers to the effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up and emphasises the person s central role in their health. Agencies should consider changes to models of care, processes and practice that impact on effective and efficient service provision and selfmanagement support. 4. Decision Support refers to the promotion of clinical care that is consistent with scientific evidence and consumer preferences. Agencies should consider the process of care delivery and how it is planned and delivered according to the use of evidence based practice guidelines, protocols, consultation with specialists and use of current information. 5. Delivery Systems Design - refers to transforming a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible. Agencies should consider the process of care delivery and how it is planned and delivered according to best practice guidelines, particularly in relation to self-management support, delivery system design, use of decision support and clinical information systems. 6. Clinical Information Systems - refers to the organisation of patient and population data to facilitate efficient and effective care. Agencies should consider processes that develop a comprehensive clinical information system to enhance the care of individual consumers by providing timely reminders for needed services, with the summarised data helping to track and plan care 7. The final survey section (Integration of Chronic Care Model Components) assesses integration of all elements of the Chronic Care Model. 31

32 Once completed and scored the tool rates each of the seven sections as limited, basic, good or excellent support for chronic illness care. The ACIC can be distributed to program managers within an agency for individual ratings that are then averaged out to achieve an organisational score. Alternatively a mix of clinicians, team leaders and managers from within an agency can complete the survey by providing an organisational response achieved through consensus. The ACIC can be implemented in small working parties guided by the PCP or external facilitator. It may be done over a series of meetings or as a half-day workshop. With an experienced facilitator, and depending on the depth of discussion, the process can take as little as 90 minutes The ACIC supports ongoing monitoring through bi-annual implementation or before and after a period of change. The same participant mix, methodology and process is to be used each time the tool is applied to optimise consistency and validity of results. PCP role in ACIC implementation Engagement of member agencies to undertake the ACIC Coordination and facilitation of workshops Development of catchment level ACIC report and Improvement Plan Support of quality improvement processes based on findings and report against progression. The level of support provided by the PCP and the format and timeframes proposed will be tailored in collaboration with each participating agency to meet the needs of the participating agencies. Agencies with a sophisticated understanding of the Wagner Chronic Care Model may wish to undertake the ACIC survey within the organisation, whereas other agencies may require a facilitated approach by the PCP. Information gathered can be utilised by agencies and at a catchment level to plan focused improvements to chronic illness care. A number of the ACIC questions may require interpretation and explanation by the ACIC facilitator, particularly as some participating agencies may not have a good understanding of the Chronic Care Model. Some of the language common to ICDM practice and used within the survey may not be well understood by respondents. For example, within Part 1 of the ACIC: Organisation of the Healthcare Delivery System, there is a question regarding incentives and regulations for chronic illness care. This language may not be typically used within Victorian agencies, and may require translation and interpretation by the ACIC facilitator in order to ensure applicability within an agency context. Typically incentive schemes are 32

33 those approaches that establish quality and cost indicators for performance for particular patient groups. General Practices or health care organisations provide data and are paid for performance on the agreed indicators; however agencies are more likely to use quality indicators for performance and link these to outcomes. PCPs undertaking a facilitated approach to the ACIC implementation may take the opportunity to run a workshop/s with agencies to re-engage agencies and refresh their understanding of the Chronic Care Model. A facilitated approach will also support standardisation across agencies in the interpretation of questions, increasing the accuracy of results. All member organisations that deliver services to those with a chronic disease are encouraged to complete the survey. PCPs are encouraged to develop a communication and/or engagement plan to influence engagement and uptake by agencies. PCPs are encouraged to report on agency engagement issues, including enablers, barriers and future opportunities within the report. Completing and scoring the ACIC Participating agencies are to complete the ACIC in the context of the delivery of an overarching chronic care model within their agency. Participating agencies are asked to rate the degree to which each component (e.g., partnerships with community organisations, patient treatment plans) is being implemented within their system for chronic and complex conditions, using a scale ranging from 0 (not at all) to 11 (fully). To aid in selecting a value, the ACIC provides general descriptions for limited, basic, good and excellent support of chronic illness care in connection with that component. One of the advantages of the ACIC is that the most advanced category (the highest possible score for each item) describes optimal practice, educating participants about where they should be targeting their practice. Scoring the ACIC The ACIC provides subscale scores corresponding to each of the Chronic Care Model elements, as well as an overall score. Scores for each section are obtained by summing the values for all items within a section (e.g., selfmanagement support) and dividing by the number of items within that section. The overall score is derived by summing the average scores of each section and dividing by the number of sections administered. For Version 3.5, you should divide the overall score by 7 (the number of subscales in Version 3.5) to obtain the average overall score. 33

34 The ACIC is organised such that the highest "score" (an "11") on any individual item, subscale, or the overall score (an average of the seven ACIC subscale scores) indicates optimal support for chronic illness. The lowest possible score on any given item or subscale is a "0", which corresponds to limited support for chronic illness care. The interpretation guidelines are as follows: Between "0" and "2" = limited support for chronic illness care Between "3" and "5" = basic support for chronic illness care Between "6" and "8" = reasonably good support for chronic illness care Between "9" and "11" = fully developed chronic illness care It is common for teams or agencies to begin a collaborative with average scores below "5" on many (or all) areas the ACIC. Over time, as teams' understanding of good care increases as they continue to implement effective practice changes as described in the improvement action plan, they should see overall improvement in their ACIC scores. Improvement Action Plan Catchment level results will assist the PCP to target ICDM and Service Coordination initiatives. PCPs will develop a catchment based Improvement Action Plan based on the six elements of care in the Chronic Care Model; community resources, health organisation, self-management support, delivery system design, decision support and clinical information systems. PCPs will need to further consider how they use the results most effectively to drive improvements and what action will be taken which will align with both the PCP strategic and operational plan. The South Coast Primary Care Partnership, has developed a resource for implementing the ACIC- Tips for Conducting Audit of Chronic Illness Care which can be accessed via the following link; The Improvement Plan (below) is from this resource and is provided as one example of ACIC Improvement Action planning. 34

35 What do you plan to do with the results? You will need to plan: How you will present the results in order to open further discussion with member agencies What action you will take in response to your results How will you take action These areas for improvement can be prioritised and broken down into small Plan Study Do Act (PSDSA) Cycles. For more information on PDSA cycles click on the link below. Australian Primary Care Collaborative: What is a PDSA? 35

36 ACIC Report The ACIC report should contain the following components as outlined (in bold). The subheadings are for consideration and guidance. 1. Introduction 1.1 Background and context 1.2 Project rationale and linkages to strategic/operational plan 2. Overview of the project 2.1 Goal 2.2 Participating Agencies 2.3 Anticipated Impacts & Benefits of Project 2.5 Consultation/Engagement Plan 2.6 Issues Management & Risk Analysis 2.7 Quality Management 3. Methodology 4. Results 3.1 Implementation of Audit Tools 3.2 Respondent selection 4.1 ACIC Data (if scoring highly, please include some examples of the work being progressed) 5. Findings/Analysis 5.1 Improvement Plan 5.2 Agency Feedback/Reflections 6. Recommendations for future Quality Improvement 7. Conclusions Further information on the ACIC is available at 36